American Society of Clinical Oncology Clinical Practice Guidelin

JOURNAL OF CLINICAL ONCOLOGY A S C O S P E C I A L A R T I C L E

Interventions to Address Sexual Problems in People WithCancer: American Society of Clinical Oncology ClinicalPractice Guideline Adaptation of Cancer CareOntario GuidelineJeanne Carter, Christina Lacchetti, Barbara L. Andersen, Debra L. Barton, Sage Bolte, Shari Damast, Michael A.Diefenbach, Katherine DuHamel, Judith Florendo, Patricia A. Ganz, Shari Goldfarb, Sigrun Hallmeyer, David M.Kushner, and Julia H. Rowland

A B S T R A C T

PurposeThe adaptation of the Cancer Care Ontario (CCO) guideline Interventions to Address SexualProblems in People With Cancer provides recommendations to manage sexual function adverseeffects that occur as a result of cancer diagnosis and/or treatment.

MethodsASCO staff reviewed the guideline for developmental rigor and updated the literature search. AnASCOExpert Panel (Table A1) was assembled to review the guideline content and recommendations.

ResultsThe ASCO Expert Panel determined that the recommendations from the 2016 CCO guideline areclear, thorough, and based upon the most relevant scientific evidence. ASCO statements andmodifications were added to adapt the CCO guideline for a broader audience.

RecommendationsIt is recommended that there be a discussion with the patient, initiated by a member of the healthcare team, regarding sexual health and dysfunction resulting from cancer or its treatment. Psy-chosocial and/or psychosexual counseling should be offered to all patients with cancer, aiming toimprove sexual response, body image, intimacy and relationship issues, and overall sexual func-tioning and satisfaction. Medical and treatable contributing factors should be identified andaddressed first. In women with symptoms of vaginal and/or vulvar atrophy, lubricants in addition tovaginal moisturizers may be tried as a first option. Low-dose vaginal estrogen, lidocaine, anddehydroepiandrosterone may also be considered in some cases. In men, medication such asphosphodiesterase type 5 inhibitors may be beneficial, and surgery remains an option for those withsymptoms or treatment complications refractory to medical management. Both women and menexperiencing vasomotor symptoms should be offered interventions for symptomatic improvement,including behavioral options such as cognitive behavioral therapy, slow breathing and hypnosis, andmedications such as venlafaxine and gabapentin.Additional information is available at: www.asco.org/survivorship-guidelines and www.asco.org/guidelineswiki.

J Clin Oncol 36:492-511. © 2017 by American Society of Clinical Oncology

INTRODUCTION

Extraordinary advances in cancer diagnosis andtreatment have led to more than 16.5 millionpeople living with and beyond cancer in theUnited States.1 Modern multimodality treatment,including surgery, radiotherapy, systemic che-motherapy, and targeted therapy, can result inshort-term and long-term adverse physical and/or

psychosocial effects. Although prevalence rates ofsexual difficulties associated with cancer and itstreatment vary depending on primary diagnosis,treatment modality, methods of assessment, andtype of sexual difficulty,2 estimates are reportedto range from 40% to 100%.3,4 This includes dis-orders of sexual desire and sexual responseinfluenced by the biologic, physiologic, and psy-chological challenges that cancer and its treat-ments present.

Author affiliations and support information

(if applicable) appear at the end of this

article.

Published at jco.org on December 11,

2017.

J.C. and J.H.R. were Expert Panel

co-chairs.

Clinical Practice Guideline Committee

approved: August 24, 2017.

Editor’s note: This American Society of

Clinical Oncology Clinical Practice

Guideline provides recommendations,

with comprehensive review and analyses

of the relevant literature for each

recommendation. Additional information,

including a Data Supplement with

additional evidence tables, aMethodology

Supplement, slide sets, clinical tools and

resources, and links to patient information

at www.cancer.net, is available at www.

asco.org/survivorship-guidelines and

www.asco.org/guidelineswiki.

Reprint requests: American Society of

Clinical Oncology, 2318Mill Rd, Suite 800,

Alexandria, VA 22314; guidelines@

asco.org.

Corresponding author: American Society

of Clinical Oncology, 2318 Mill Rd, Suite

800, Alexandria, VA 22314; e-mail:

[email protected].

© 2017 by American Society of Clinical

Oncology

0732-183X/18/3605w-492w/$20.00

ASSOCIATED CONTENT

Appendix

DOI: https://doi.org/10.1200/JCO.

2017.75.8995

Data Supplement

DOI: https://doi.org/10.1200/JCO.

2017.75.8995

DOI: https://doi.org/10.1200/JCO.2017.

75.8995

492 © 2017 by American Society of Clinical Oncology

VOLUME 36 • NUMBER 5 • FEBRUARY 10, 2018

Downloaded from ascopubs.org by 97.127.187.121 on May 5, 2018 from 097.127.187.121Copyright © 2018 American Society of Clinical Oncology. All rights reserved.

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http://www.asco.org/guidelineswiki

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http://www.cancer.net




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THE BOTTOM LINE

Interventions to Address Sexual Problems in People With Cancer: American Society of Clinical Oncology ClinicalPractice Guideline Adaptation of Cancer Care Ontario Guideline

Guideline QuestionWhat is the effectiveness of pharmacological interventions, psychosocial counseling, or devices to manage sexual problems after cancertreatment? More specifically, issues in men and in women were examined separately.

Target PopulationThis guideline is applicable to adult ($ 18 years of age) men and women (and their partners) of all sexual orientations living withcancer of any type. For the purposes of this guideline, men and women who were previously treated for a childhood cancer were notincluded.

Target AudienceHealth care practitioners, such as oncologists, urologists, gynecologists, primary care providers, surgeons, nurses, physiotherapists,social workers, counselors, psychologists, psychiatrists, and sex therapists/counselors, and advanced practice providers, such asphysician assistants and nurse practitioners.

ASCO Recommendations for Interventions to Address Sexual Problems in People With CancerThe ASCO Expert Panel’s modifications to Cancer Care Ontario’s (CCO’s) recommendations and qualifying statements appear in bolditalics. ASCO’s own qualifying statements appear in italics. A list of the original CCO recommendations can be found in Table 1.

For All People With Cancer

Recommendation 1. It is recommended that there be a discussion with the patient, initiated by a member of the health care team,regarding sexual health and dysfunction resulting from the cancer or its treatment. The conversation could include the patient’spartner, only if the patient so wishes. This issue should be raised with the individual at the time of diagnosis and continue to bereassessed periodically throughout follow-up. The Expert Panel believes that this is a vital recommendation. The recommendationsthat follow cannot be used unless someone has taken the initiative to ask.

It is recommended that there be access to resources or referral information for the patient (and partner).

ASCOQualifying Statement. The Expert Panel believes that introduction of the topic of sexual function should be held with the patient alone,with the option of later partner inclusion if desired by the patient. Discussions should be congruent with the patient’s literacy level, cultural/religious beliefs, and sexual orientation. This discussion should be offered at varied points of treatment and survivorship to assess or addressany changes.

For Women With Cancer

CONDITION: SEXUAL RESPONSERecommendation 1. The Expert Panel believes that psychosocial and/or psychosexual counseling should be offered to women withcancer, aiming to improve elements of sexual response such as desire, arousal, or orgasm. Current evidence does not support one typeof psychosocial or psychosexual counseling to be superior to another.

Clinicians may offer flibanserin to premenopausal women who are experiencing hypoactive sexual desire disorder.14,15

CCO Qualifying Statement. It is the opinion of the Expert Panel that any kind of regular stimulation (including masturbation) wouldlikely be of benefit for improving sexual response, regardless of the stimulation used.

ASCO Qualifying Statement. It should be noted that flibanserin has not been evaluated in women with a history of cancer or those onendocrine therapy. In addition, the risk/benefit ratio for this medication is uncertain.

CONDITION: BODY IMAGERecommendation 2. It is recommended that psychosocial counseling be offered to women with cancer and body image issues.

If a woman is partnered, evidence indicates that couples-based interventions are effective when compared with usual care.(continued on following page)

jco.org © 2017 by American Society of Clinical Oncology 493

Sexual Problems in People With Cancer Guideline Adaptation


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THE BOTTOM LINE (CONTINUED)

No recommendation can be made for or against group therapy (with or without exercise) for women with body image issues.

ASCOQualifying Statement. Clinicians should assess for body image issues early and often in the cancer care continuum and should take intoaccount cultural and/or religious variations. Patients with preexisting depression and/or body image issues may be at a higher risk ofsusceptibility.

CONDITION: INTIMACY/RELATIONSHIPSRecommendation 3. It is recommended that psychosocial counseling be offered to women with cancer aiming to improve intimacy andrelationship issues. If a woman is partnered, evidence indicates that couples-based interventions are effective when compared withusual care.

ASCO Qualifying Statement. The Expert Panel views partner involvement in all cases to be the choice of the patient.

CONDITION: OVERALL SEXUAL FUNCTIONING AND SATISFACTIONRecommendation 4. The Expert Panel believes that psychosocial counseling directed at the individual or couple or delivered in a groupbe offered to women with cancer who have problems with overall sexual functioning. Physical exercise or pelvic floor physiotherapy, inaddition to psychosocial counseling, may also be of benefit.

Current evidence does not support a specific psychosocial counseling intervention to improve sexual functioning and satisfaction.

Health care providers should screen patientswith cancer for overall sexual functioning and satisfaction, and a diagnosisshould be established when there are physical issues playing a contributing role.

All patients should be offered education and symptom management based on the patient’s diagnosis. For patientshaving persistent concerns, such as physical issues, a gynecologic examination would be ideal. For those continuing tohave relationship issues and/or distress, mental health counseling should be an option.

ASCO Qualifying Statement. The ASCO Expert Panel believes patients can still benefit if counseling is provided by licensed counselorsavailable at the medical center even if specialized therapists (eg, sex therapists) are not available.

CONDITION: VASOMOTOR SYMPTOMSRecommendation 5. For women with vasomotor symptoms, hormone therapy is the most effective intervention. For women unwillingor unable to use hormonal therapy, alternatives exist: for example, paroxetine, venlafaxine, gabapentin, or clonidine.

Having a hormone-sensitive breast cancer is a contraindication to using systemic hormone therapy.

Psychosocial counseling (cognitive behavioral therapy) and/or clinical hypnosis may provide a benefit and reduce vasomotorsymptoms and should be offered.16-19

CCO Qualifying Statement. The Expert Panel emphasizes that women with non–hormone-sensitive cancers who develop vasomotorsymptoms from their cancer treatment should be counseled to consider hormone therapy until the average age of menopause,approximately 51 years, at which point they should be re-evaluated. Risks typically cited for hormone therapy are derived from studiesof postmenopausal women. Beyond the age of 51 years, hormone therapy is an individual therapy with few risks for symptomaticpatients in their 50s. It should be intermittently evaluated for long-term use.

When not contraindicated, estrogen therapy alone (oral, transdermal, or vaginal) is recommended for women who have hada hysterectomy, as it has a more beneficial risk/benefit profile.

Paroxetine and fluoxetine should not be offered to women with breast cancer taking tamoxifen. Adverse events of clonidine includehypotension, light-headedness, headache, dry mouth, dizziness, sedation, and constipation. Sudden cessation can lead to significantelevations in blood pressure.

ASCOQualifying Statement. The use of systemic hormone therapy is not necessarily contraindicated in patients with other hormone-sensitivecancers like endometrial and ovarian cancer. Clinicians should discuss all options, including integrative approaches, with their patient,outlining the benefits and risks of each.

CONDITION: GENITAL SYMPTOMSRecommendation 6. The Expert Panel believes that for women with symptoms of vaginal and/or vulvar atrophy, such as dryness,the following stepwise approach should be followed:

(continued on following page)

494 © 2017 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY

Carter et al



Lubricants for all sexual activity or touch, in addition to vaginal moisturizers to improve vulvovaginal tissue quality, maybe tried first. It should be noted that moisturizers may need to be applied at a higher frequency (three to five times perweek) in the vagina, at the vaginal opening, and on the external folds of the vulva for symptom relief in female patientswith cancer and survivors.151

For those who do not respond or whose symptoms are more severe at presentation, low-dose vaginal estrogen can be used. For womenwith hormone-positive breast cancer who are symptomatic and not responding to conservative measures, low-dose vaginal estrogencan be considered after a thorough discussion of risks and benefits.

Lidocaine can also be offered for persistent introital pain and dyspareunia.152

For women with current or a history of breast cancer who are on aromatase inhibitors and have not responded toprevious treatment, clinicians may offer vaginal dehydroepiandosterone.20-23

Finally, clinicians may offer the selective estrogen receptor modulator ospemifene to postmenopausal women withoutcurrent or a history of breast cancer who are experiencing dyspareunia, vaginal atrophy, or other vaginal pain.24-26

Clinicians should offer pain relievers to women on aromatase inhibitors who are experiencing arthralgia that interfereswith intimacy.

Clinicians may suggest the use of skin protectants/sealants applied to the external folds of the vulva in women usingpads for leakage and/or discharge.

Vaginal dilators may be of benefit in the management of vaginismus and/or vaginal stenosis and can be offered to anyone having painwith examinations and/or sexual activity. This is particularly important for women treated with pelvic (or vaginal) radiationtherapy. Ideally, benefit is greatest when started early and should not be recommended based on sexual activity or sexual orientationbut, rather, to all women at risk for vaginal changes to be proactive in their sexual and vulvovaginal health.

Cognitive behavioral therapy and pelvic floor (Kegel) exercisesmay be useful to decrease anxiety and discomfort and can lower urinarytract symptoms.

The Expert Panel believes that pelvic floor physiotherapy may be beneficial for patients experiencing symptoms of a potential pelvicfloor dysfunction, including persistent pain and urinary and/or fecal leakage. Clinicians may refer patients to a urologist orurogynecologist for further evaluation and treatment of urinary incontinence or to a colorectal surgeon for fecal incontinence.

ASCOQualifying Statement. There is limited supportive data on the use of vaginal dehydroepiandosterone in women with a history of canceror on endocrine therapy, so the risk/benefit for this population is not fully known. Ospemifene has not been evaluated in women with a historyof cancer or on endocrine therapy, and therefore, the risk/benefit is not known for this population. A thorough discussion outlining theuncertainty should be had with the patient.

For Men With Cancer

CONDITION: SEXUAL RESPONSERecommendation 1. It is recommended that phosphodiesterase type 5 inhibitor (PDE5i) medications be used to help men with erectiledysfunction.

Men who do not respond to PDE5i medications should consider alternate interventions, such as a vacuum erectile device (VED),medicated urethral system for erection, or intracavernosal injection.

There may be some benefit to initiating the use of any of the above interventions earlier after cancer treatment rather than later.Introduction prior to treatment initiation may be of benefit to some men.





http://jco.org


Surgical interventions, including penile prosthesis implantation for erectile dysfunction, can be offered to patients whoare not responding to conventional medical therapy or reporting adverse effects with such therapy.

Clinicians may refer patients to a urologist for evaluation and treatment of stress urinary incontinence.

CCO Qualifying Statement. The Expert Panel believes that men are best served by being offered a combination of psychosocialcounseling with the aim of greater adaptation toward long-term use and PDE5i medication adherence together with PDE5i treatment.For men who are partnered, psychosocial counseling should be directed at the couple.

Men should be aware that it might take a long time for medications to work and that PDE5i medications might not work for all men,especially in those with preexisting comorbidities. Clinicians should discuss with patients the appropriate duration of use andalternative options (eg, surgery) if the medications fail to work satisfactorily.

It is the opinion of the Expert Panel that any kind of regular stimulation (including masturbation) would likely be of benefit forimproving sexual response, regardless of the stimulation used.

Contraindications include the use of nitrates in any form. Common acute adverse effects of PDE5i medications include headaches,flushing, dizziness, upset stomach, nasal congestion, and dyspepsia.

CONDITION: GENITAL CHANGESRecommendation 2. It is recommended that a VED be used daily to prevent penis length loss. There may be some benefit to initiatingthe use of VEDs earlier after cancer treatment rather than later. Early treatment with PDE5i medications may also be beneficial for thisoutcome.

CONDITION: INTIMACY/RELATIONSHIPSRecommendation 3. The Expert Panel believes that individual or couples counseling should be offered for those wishing toimprove relationship or intimacy issues. Current evidence does not support a particular intervention to improve intimacy orrelationships.

ASCO Qualifying Statement. The opportunity for partners to be involved should be offered rather than viewed as a necessarycondition.

CONDITION: OVERALL SEXUAL FUNCTIONING AND SATISFACTIONRecommendation 4: It is recommended that psychosocial counseling be offered to men with cancer (and partners) to potentiallyimprove sexual functioning and satisfaction. It is also recommended that the use of pro-erectile agents and devices be considered,recognizing that most of the benefit is specifically for erectile dysfunction. With men who have sex with men, additional educationmay need to be provided on the changes in erection and alternative ways to maintain sexual intimacy.

Body image, including such issues as weight changes, disfigurement, scarring, and hair loss, should be discussed andnormalized in men.

Clinicians should check testosterone levels, even if the patient has a cancer that is not typically associated withhormone changes. Options should be discussed when testosterone levels are within normal range but the patient orclinician feels supplementation can have a clinical benefit and is not contraindicated.

CCO Qualifying Statement. Psychosocial counseling could be used to help couples integrate interventions into their usual sexualactivities.

CONDITION: VASOMOTOR SYMPTOMSRecommendation 5. Men with vasomotor symptoms should be offered medication for symptomatic improvements. Options wouldinclude venlafaxine, medroxyprogesterone acetate, cyproterone acetate, and gabapentin. Acupuncture may be a suitable alternative, asmay be other integrative medicine options, such as slow-breathing techniques and hypnosis, as evidence demonstrates clinical benefitin women.



Carter et al


Sexual health is an integral component of quality of life acrossthe lifespan. Cancer survivors who experience sexual morbidity areat an increased risk of distress and poor quality of life. Impairedemotional well-being and quality of life in turn contribute tohigher rates of morbidity and mortality among affected cancersurvivors.5,6 Sexual problems commonly include decreased desire,arousal disorders, pain (largely in women), and erectile dysfunc-tion (in men). In addition to cultural and religious influences,sexual function is affected in a multifactorial way by one’s overallhealth (the patient’s and that of his/her partner), partner re-lationships, previous sexual history, medications, fatigue and stress,mood, view of sexual self, body image, incontinence, and hor-monal changes. Cancer can independently affect sexual function bythe nature of the disease and its treatment and/or result in changesto health, body image, or view of sexual self, and altered re-lationships secondary to illness.

There remains an overall reluctance from both clinicians andpatients to talk about cancer- and treatment-related sexualdifficulties.2,7,8 Barriers from the clinician’s perspective can includefeeling inadequately trained or insufficiently skilled, limitedawareness of effective interventions, lack of time, lack of privacy,and concerns about making patients feel uncomfortable.9 Beyondthese reasons, studies also suggest that clinicians may make as-sumptions based on factors such as age and presumed interest,overall prognosis, and whether the patient has a current partner.10

For patients, barriers similarly may include concerns about makingthe doctor feel uncomfortable, embarrassment around the topic,belief that it is the clinician’s responsibility to raise the issue, andthat their sexual health concerns are not valid or are an expectedand untreatable complication of their disease and itstreatment.9,11-13

In 2016, Cancer Care Ontario (CCO) released guideline rec-ommendations regarding interventions to improve sexual functionin individuals with cancer. ASCO has established a process forendorsing and/or adapting other organizations’ clinical practiceguidelines. This article summarizes the results of that process andpresents the adapted practice recommendations.

The original CCO recommendations appear in Table 1 and onlineat https://www.cancercareontario.ca/en/content/interventions-address-sexual-problems-people-cancer.

OVERVIEW OF THE ASCO GUIDELINE ADAPTATION PROCESS

ASCO has policies and procedures for endorsing and/or adaptingpractice guidelines that have been developed by other professionalorganizations, with the goal of increasing the number of high-quality, ASCO-vetted guidelines available to the ASCO member-ship. The ASCO endorsement process involves an assessment byASCO staff of candidate guidelines for methodological qualityusing the Rigor of Development subscale of the Appraisal ofGuidelines for Research and Evaluation II (AGREE II) instrument.(See Methodology Supplement for more details.) The CCOguideline for Interventions to Address Sexual Problems in PeopleWith Cancer rated highly on the AGREE II instrument and wasidentified as a potential candidate for endorsement by ASCO.During the endorsement process, modifications and qualifyingstatements were made by the ASCO Expert Panel (Appendix TableA1, online only) to improve the guideline’s applicability to the broaderASCO guideline audience. Due to the number and significance ofthese changes, the ASCO Clinical Practice Guidelines Committeeleadership agreed that this product should be considered a guidelineadaptation, and it was labeled as such going forward. All funding forthe administration of the project was provided by ASCO.

DisclaimerThe clinical practice guidelines and other guidance published

herein are provided by the American Society of Clinical Oncology,Inc. (“ASCO”) to assist providers in clinical decision-making. Theinformation therein should not be relied upon as being complete oraccurate, nor should it be considered as inclusive of all propertreatments or methods of care or as a statement of the standard ofcare. With the rapid development of scientific knowledge, new


Psychosocial counseling (cognitive behavioral therapy) may provide a benefit and reduce vasomotor symptoms andshould be offered.

ASCO Qualifying Statement. Evidence supporting the clinical effectiveness of various integrative medicine techniques exists for womenexperiencing vasomotor symptoms.16-19 The ASCO Expert Panel feels extrapolation to male patients is reasonable and an option for mensuffering from vasomotor symptoms.

Additional ResourcesMore information, including a Data Supplement, a Methodology Supplement, slide sets, and clinical tools and resources, is available atwww.asco.org/survivorship-guidelines and www.asco.org/guidelineswiki. Patient information is available at www.cancer.net.

A link to the guideline, Interventions to Address Sexual Problems in People With Cancer, can be found at https://www.cancercareontario.ca/en/content/interventions-address-sexual-problems-people-cancer

ASCO believes that cancer clinical trials are vital to informmedical decisions and improve cancer care, and that all patients shouldhave the opportunity to participate.




https://www.cancercareontario.ca/en/content/interventions-address-sexual-problems-people-cancer







http://jco.org

Table1.

Orig

inal

CCO

andASCO

Ada

pted

Rec

ommen

datio

nsan

dQua

lifying

Statemen

ts

CCO

Rec

ommen

datio

nCCO

Qua

lifying

Statemen

tASCO

Ada

pted

Rec

ommen

datio

nASCO

Qua

lifying

Statemen

t

Forallp

eoplewith

canc

erRec

ommen

datio

n1.

Itis

reco

mmen

dedthat

therebe

adiscus

sion

with

thepa

tient,initiated

byamem

berof

thehe

alth

care

team

,reg

arding

sexu

alhe

alth

anddy

sfun

ctionresu

lting

from

the

canc

eror

itstrea

tmen

t.Idea

lly,the

conv

ersatio

nwou

ldinclud

ethepa

tient’s

partne

r,ifpa

rtne

red.

This

issu

esh

ould

beraised

atthetim

eof

diag

nosisan

dco

ntinue

tobe

reas

sess

edpe

riodica

llythroug

hout

follow-up.

TheExp

ertPan

elbe

lieve

sthat

this

isavital

reco

mmen

datio

n.Th

ereco

mmen

datio

nsthat

follow

cann

otbe

used

unless

someo

neha

stake

ntheinitiativeto

ask.

Itis

reco

mmen

dedthat

therebe

acce

ssto

reso

urce

sor

referral

inform

ationforthepa

tient

(and

partne

r).

Non

eRec

ommen

datio

n1.

Itis

reco

mmen

dedthat

therebe

adiscus

sion

with

thepa

tient,initia

tedby

amem

berof

thehe

alth

care

team

,rega

rdingse

xual

health

and

dysfun

ctionresu

lting

from

theca

ncer

orits

trea

tmen

t.Th

eco

nversa

tionco

uldinclud

ethepa

tient’s

partne

r,on

lyifthepa

tient

sowishe

s.Th

isissu

esh

ould

beraised

with

theindividu

alat

thetim

eof

diag

nosisan

dco

ntinue

tobe

reas

sess

edpe

riodica

llythroug

hout

follow-up.

TheExp

ertPan

elbe

lieve

sthat

this

isavital

reco

mmen

datio

n.Th

ereco

mmen

datio

nsthat

follow

cann

otbe

used

unless

someo

neha

stake

ntheinitiative

toask.

Itisreco

mmen

dedthat

therebe

acce

ssto

reso

urce

sor

referral

inform

ationforthepa

tient

(and

partne

r).

ASCO

Qua

lifying

Statemen

t.The

Expe

rtPa

nel

belie

vesthat

introd

uctio

nof

thetopicof

sexu

alfunc

tionsh

ould

behe

ldwith

thepa

tient

alon

e,with

theop

tionof

laterp

artner

inclus

ionifde

sired

bythepa

tient.Discu

ssions

shou

ldbe

cong

ruen

twith

thepa

tient’s

literac

yleve

l,cu

ltural/religious

belie

fs,an

dse

xual

orientation.

Thisdisc

ussion

shou

ldbe

offeredat

varie

dpo

ints

oftrea

tmen

tan

dsu

rvivorsh

ipto

asse

ssor

addres

san

ych

ange

s.

Forwom

enwith

canc

erSex

ualR

espo

nse

Rec

ommen

datio

n1.

TheExp

ertPan

elbe

lieve

sthat

psyc

hoso

cial

coun

selingsh

ould

beofferedto

wom

enwith

canc

er,aimingto

improv

eelem

ents

ofse

xualresp

onse

such

asde

sire,arou

sal,or

orga

sm.Current

eviden

cedo

esno

tsu

pporton

etype

ofps

ycho

social

psyc

hose

xual

educ

ationan

dco

unse

lingto

besu

perio

rto

anothe

r.Noreco

mmen

datio

nca

nbe

mad

efor

pharmac

olog

ical

interven

tions

.

Itistheop

inionof

theExp

ertP

anel

that

anykind

ofregu

larstim

ulation(in

clud

ingmasturbation)

wou

ldlikelybe

ofbe

nefitforim

prov

ingse

xual

resp

onse

,rega

rdless

ofthestim

ulation.

Rec

ommen

datio

n1.

TheExp

ertPan

elbe

lieve

sthat

psycho

social

and/or

psyc

hose

xual

coun

selingsh

ould

beofferedto

wom

enwith

canc

er,aimingto

improv

eelem

ents

ofse

xualresp

onse

such

asde

sire,arous

al,o

rorga

sm.C

urrent

eviden

cedo

esno

tsup

porton

etype

ofps

ycho

social

orps

ycho

sexu

aled

ucationan

dco

unse

lingto

besu

perio

rto

anothe

r.Clin

icians

may

offerfliba

nserin

toprem

enop

ausa

lwom

enwho

areex

perie

ncinghy

poac

tivese

xual

desire

diso

rder.1

4,15

Itistheop

inionof

theExp

ertP

anel

that

anykind

ofregu

larstim

ulation(in

clud

ingmasturbation)

wou

ldlikelybe

ofbe

nefitforim

prov

ingse

xual

resp

onse

,rega

rdless

ofthestim

ulation.

ASCO

Qua

lifying

Statemen

t.Itsh

ould

beno

ted

that

fliba

nserin

hasno

tbee

nev

alua

tedin

wom

enwith

ahistoryof

canc

eror

thos

eon

endo

crine

therap

y.In

additio

n,theris

k/be

nefit

ratio

forthis

med

icationis

unce

rtain.

Bod

yim

age

Rec

ommen

datio

n2.

Itis

reco

mmen

dedthat

psyc

hoso

cialco

unse

lingbe

offeredto

wom

enwith

canc

eran

dbo

dyim

ageissu

es.

Ifawom

anis

partne

red,

eviden

ceindica

tes

that

coup

les-ba

sedinterven

tions

areeffective

whe

nco

mpa

redwith

usua

lcare.

Noreco

mmen

datio

nca

nbe

mad

eforor

agains

tgrou

ptherap

y(w

ithor

with

out

exercise

)for

wom

enwith

body

imag

eissu

es.

Non

eRec

ommen

datio

n2.

Itis

reco

mmen

dedthat

psycho

social

coun

selingbe

offeredto

wom

enwith

canc

eran

dbo

dyim

ageissu

es.

Ifawom

anis

partne

red,

eviden

ceindicatesthat

coup

les-ba

sedinterven

tions

areeffectivewhe

nco

mpa

redwith

usua

lcare.

Noreco

mmen

datio

nca

nbe

mad

eforor

agains

tgrou

ptherap

y(w

ithor

with

oute

xercise)

forw

omen

with

body

imag

eissu

es.

ASCO

Qua

lifying

Statemen

t.Clin

icians

shou

ldas

sess

forbo

dyim

ageissu

esea

rlyan

doftenin

theca

ncer

care

continuu

man

dsh

ould

take

into

acco

untcu

lturala

nd/orrelig

ious

varia

tions

.Pa

tientswith

pree

xistingde

pres

sion

and/or

body

imag

eissu

esmay

beat

ahigh

erris

kof

susc

eptib

ility.

Intim

acy/relatio

nships

Rec

ommen

datio

n3.

Itis

reco

mmen

dedthat

psyc

hoso

cialco

unse

lingbe

offeredto

wom

enwith

canc

eraimingto

improv

eintim

acyan

drelatio

nshipissu

es.

Ifawom

anis

partne

red,

eviden

ceindica

tes

that

coup

les-ba

sedinterven

tions

areeffective

whe

nco

mpa

redwith

usua

lcare.

Non

eRec

ommen

datio

n3.

Itis

reco

mmen

dedthat

psycho

social

coun

selingbe

offeredto

wom

enwith

canc

eraimingto

improv

eintim

acyan

drelatio

nship

issu

es.

Ifawom

anis

partne

red,

eviden

ceindicatesthat

coup

les-ba

sedinterven

tions

areeffectivewhe

nco

mpa

redwith

usua

lcare.

ASCO

Qua

lifying

Statemen

t.The

Expe

rtPa

nel

view

spa

rtne

rinvo

lvem

entin

allc

ases

tobe

the

choice

ofthepa

tient.

(con

tinue

don

followingpa

ge)


Carter et al


Table1.

Orig

inal

CCO

andASCO

Ada

pted

Rec

ommen

datio

nsan

dQua

lifying

Statemen

ts(con

tinue

d)

CCO

Rec

ommen

datio

nCCO

Qua

lifying

Statemen

tASCO

Ada

pted

Rec

ommen

datio

nASCO

Qua

lifying

Statemen

t

Ove

rallse

xual

func

tioning

andsatis

faction

Rec

ommen

datio

n4.

TheExp

ertPan

elbe

lieve

sthat

psyc

hoso

cial

coun

seling

directed

attheindividu

alor

coup

leor

delivered

inagrou

pbe

offeredto

wom

enwith

canc

erwho

have

prob

lemswith

overalls

exua

lfunc

tioning

.Phy

sica

lexe

rciseor

pelvic

floo

rph

ysiotherap

y,in

additio

nto

psycho

social

coun

seling,

may

also

beof

bene

fit.

Current

eviden

cedo

esno

tsu

pportasp

ecific

psyc

hoso

cial

coun

selinginterven

tionto

improv

ese

xual

func

tioning

andsatis

faction.

Non

eRec

ommen

datio

n4.

TheExp

ertPan

elbe

lieve

sthat

psycho

social

coun

selingdirected

attheindividu

alor

coup

leor

delivered

inagrou

pbe

offeredto

wom

enwith

canc

erwho

have

prob

lemswith

overalls

exua

lfunc

tioning

.Phy

sicale

xerciseor

pelvic

floo

rph

ysiotherap

y,in

additio

nto

psycho

social

coun

seling,

may

also

beof

bene

fit.

Current

eviden

cedo

esno

tsu

pportasp

ecific

psyc

hoso

cialco

unse

linginterven

tionto

improv

ese

xual

func

tioning

andsa

tisfaction.

Hea

lthca

reprov

iderssh

ould

screen

patie

ntswith

canc

erforo

verallse

xual

func

tioning

andsa

tisfaction,

andadiag

nosissh

ould

bees

tablishe

dwhe

nthereare

phys

ical

issu

esplay

ingaco

ntrib

utingrole.

Allpa

tientssh

ould

beoffereded

ucationan

dsy

mptom

man

agem

entba

sedon

thepa

tient’s

diag

nosis.

For

patie

ntsha

ving

persistent

conc

erns

,suc

has

phys

ical

issu

es,a

gyne

cologicex

aminationwou

ldbe

idea

l.Fo

rthos

eco

ntinuing

toha

verelatio

nshipissu

esan

d/or

distress,men

talh

ealth

coun

selin

gsh

ould

bean

optio

n.

ASCO

Qua

lifying

Statemen

t.The

ASCO

Expe

rtPa

nelb

elieve

spa

tientsca

nstill

bene

fitif

coun

selin

gis

prov

ided

bylic

ense

dco

unse

lors

availableat

themed

ical

center

even

ifsp

ecialized

therap

ists

(eg,

sextherap

ists)areno

tav

ailable.

Vas

omotor

symptom

sRec

ommen

datio

n5.

Forwom

enwith

vaso

motor

symptom

s,ho

rmon

etherap

yisthe

mos

teffectiveinterven

tion.

Forwom

enun

willingor

unab

leto

useho

rmon

altherap

y,alternatives

exist;forex

ample,

paroxe

tine,

venlafax

ine,

gaba

pentin,or

clon

idine.

Havingaho

rmon

e-se

nsitive

brea

stcanc

eris

aco

ntraindica

tionto

usingsy

stem

icho

rmon

etherap

y.Psy

chos

ocialc

ouns

eling(cog

nitiv

ebe

havioral

therap

y)may

prov

ideabe

nefitan

dredu

ceva

somotor

symptom

san

dsh

ould

beoffered.

TheExp

ertPan

elem

phas

izes

that

wom

enwith

non–

horm

one-se

nsitive

canc

erswho

deve

lop

vaso

motor

symptom

sfrom

theirc

ance

rtreatmen

tsh

ould

beco

unse

ledto

cons

ider

horm

onetherap

yun

tiltheav

erag

eag

eof

men

opau

se,app

roximately

51ye

ars,

atwhich

pointthey

shou

ldbe

re-

evalua

ted.

Risks

typically

citedforho

rmon

etherap

yarede

rived

from

stud

iesof

postmen

opau

salw

omen

.Bey

ondtheag

eof

51ye

ars,

horm

onetherap

yis

anindividu

altherap

ywith

few

risks

forsymptom

atic

patie

ntsin

their

50s.

Itsh

ould

beinterm

itten

tlyev

alua

tedforlong

-term

use.

Whe

nno

tcon

traind

icated

,estroge

ntherap

yalon

e(oral,tran

sdermal,o

rvagina

l)is

reco

mmen

dedfor

wom

enwho

have

hadahy

sterec

tomy,

asitha

samorebe

neficial

risk/be

nefitprofi

le.

Parox

etinean

dfluo

xetin

esh

ould

notb

eofferedto

wom

enwith

brea

stcanc

ertaking

tamox

ifen.

Adv

erse

even

tsof

clon

idineinclud

ehy

potens

ion,

light-hea

dedn

ess,

head

ache

,dry

mou

th,d

izzine

ss,

seda

tion,

andco

nstip

ation.

Sud

dence

ssationcan

lead

tosign

ificant

elev

ations

inbloo

dpres

sure.

Rec

ommen

datio

n5.

Forwom

enwith

vaso

motor

symptom

s,ho

rmon

etherap

yis

themos

teffective

interven

tion.

Forwom

enun

willingor

unab

leto

use

horm

onal

therap

y,alternatives

exist:forex

ample,

paroxe

tine,

venlafax

ine,

gaba

pentin,or

clon

idine.

Hav

ingaho

rmon

e-se

nsitive

brea

stca

ncer

isaco

ntraindica

tionto

usingsy

stem

icho

rmon

etherap

y.Psy

chos

ocialc

ouns

eling(cog

nitiv

ebe

havioral

therap

y)an

d/or

clinical

hypn

osis

may

prov

ideabe

nefitan

dredu

ceva

somotor

symptom

san

dsh

ould

beoffered.

16-19

ASCO

Qua

lifying

Statemen

t.Th

eExp

ertPan

elem

phas

izes

that

wom

enwith

non–

horm

one-

sens

itive

canc

erswho

deve

lopvaso

motor

symptom

sfrom

theirca

ncer

trea

tmen

tsh

ould

beco

unse

ledto

cons

ider

horm

onetherap

yun

tilthe

averag

eag

eof

men

opau

se,ap

prox

imately51

years,

atwhich

pointthey

shou

ldbe

re-eva

luated

.Risks

typically

citedforho

rmon

etherap

yare

deriv

edfrom

stud

iesof

postmen

opau

salw

omen

.Bey

ondtheag

eof

51ye

ars,ho

rmon

etherap

yisan

individu

altherap

ywith

few

risks

forsy

mptom

atic

patie

ntsin

their50

s.Itsh

ould

beinterm

itten

tlyev

alua

tedforlong

-term

use.

The

useof

system

icho

rmon

etherap

yis

not

nece

ssarily

contraindica

tedin

patie

ntswith

othe

rho

rmon

e-se

nsitive

canc

erslik

een

dometria

land

ovarianca

ncer.Clin

icians

shou

lddisc

ussion

all

optio

ns,includ

ingintegrativeap

proa

ches

,with

theirpa

tient,ou

tlining

thebe

nefitsan

dris

ksof

each

.Whe

nno

tcon

traind

icated

,estroge

ntherap

yalon

e(oral,tran

sdermal,o

rva

gina

l)is

reco

mmen

dedfor

wom

enwho

have

hadahy

sterec

tomy,

asitha

samorebe

neficial

risk/be

nefitprofi

le.

Parox

etinean

dfluo

xetin

esh

ould

notb

eofferedto

wom

enwith

brea

stca

ncer

taking

tamox

ifen.

Adv

erse

even

tsof

clon

idineinclud

ehy

potens

ion,

light-hea

dedn

ess,

head

ache

,dry

mou

th,d

izzine

ss,

seda

tion,

andco

nstip

ation.

Sud

dence

ssationca

nlead

tosign

ifica

ntelev

ations

inbloo

dpres

sure.

(con

tinue

don

followingpa

ge)




http://jco.org

Table1.

Orig

inal

CCO

andASCO

Ada

pted

Rec

ommen

datio

nsan

dQua

lifying

Statemen

ts(con

tinue

d)

CCO

Rec

ommen

datio

nCCO

Qua

lifying

Statemen

tASCO

Ada

pted

Rec

ommen

datio

nASCO

Qua

lifying

Statemen

t

Gen

itals

ymptom

sRec

ommen

datio

n6.

Wom

enwith

symptom

sof

vagina

latrop

hy,su

chas

vagina

ldryne

ss,

shou

ldbe

man

aged

inthesa

meway

aswom

enwith

outca

ncer.Vag

inal

moisturizers

ford

ailyco

mfortan

d/or

lubrican

tswith

sexu

alac

tivity

may

betried.

Forthos

ewho

dono

tresp

ondor

who

sesy

mptom

saremorese

vere

atpres

entatio

n,va

gina

lestroge

nca

nbe

safely

used

.Vag

inal

dilators

may

beof

bene

fitin

the

man

agem

entof

vaginism

usan

d/or

vagina

lsten

osis.

Cog

nitiv

ebe

havioral

therap

yan

dex

ercise

may

beus

eful

tode

crea

selower

urinarytrac

tsy

mptom

s.Th

eExp

ertPan

elbe

lieve

sthat

pelvic

floo

rph

ysiotherap

ysh

ould

also

beofferedto

wom

enwith

pain

orothe

rpe

lvic

floo

rissu

es.

Forwom

enwith

horm

one-po

sitiv

ebrea

stcanc

erwho

aresy

mptom

atic

andno

tresp

onding

toco

nservativ

emea

sures,

vagina

lestroge

ncanbe

cons

idered

afteradiscus

sion

.

Rec

ommen

datio

n6.

The

Expe

rtPa

nelb

elieve

sthat

for

wom

enwith

symptom

sof

vagina

land

/orvu

lvar

atroph

y,su

chas

dryn

ess,

thefollo

wingstep

wise

approa

chsh

ould

befollo

wed

:Lu

brican

tsforalls

exua

lactivity

ortouc

h,in

additio

nto

vagina

lmoisturizersto

improv

evu

lvov

aginal

tissu

equ

ality

,may

betriedfirst.Itsh

ould

beno

tedthat

moisturizersmay

need

tobe

appliedat

ahigh

erfreq

uenc

y(three

tofiv

etim

espe

rwee

k)in

theva

gina

,at

theva

gina

lope

ning

,and

ontheex

ternalfoldsof

the

vulvaforsy

mptom

relie

fin

femalepa

tientswith

canc

eran

dsu

rvivors.

151

Fortho

sewho

dono

tres

pond

orwho

sesy

mptom

sare

morese

vere

atpres

entatio

n,low-dos

eva

gina

les

trog

enca

nbe

used

.Fo

rwom

enwith

horm

one-

positiv

ebrea

stca

ncer

who

aresy

mptom

atic

andno

tresp

onding

toco

nserva

tivemea

sures,

low-dos

evagina

lestroge

ncanbe

cons

idered

afterathorou

ghdiscus

sion

ofris

ksan

dbe

nefits.

Lido

caineca

nalso

beofferedforpe

rsistent

introital

pain

anddy

spareu

nia.

152

Forwom

enwith

curren

tor

ahistoryof

brea

stca

ncer

who

areon

arom

atas

einhibitors

andha

veno

tresp

onde

dto

prev

ious

trea

tmen

t,clinicians

may

offer

vagina

ldeh

ydroep

iand

osterone

.20-23

Fina

lly,clinicians

may

offerthese

lectivees

trog

enrece

ptor

mod

ulator

ospe

mife

neto

postmen

opau

sal

wom

enwith

outcu

rren

tor

ahistoryof

brea

stca

ncer

who

areex

perie

ncingdy

spareu

nia,

vagina

latrop

hy,o

rothe

rva

gina

lpain.

24-26

Clin

icians

shou

ldofferpa

inrelie

vers

towom

enon

arom

atas

einhibitors

who

areex

perie

ncingarthralgia

that

interferes

with

intim

acy.

Clin

icians

may

sugg

esttheus

eof

skin

protec

tants/

sealan

tsap

pliedto

theex

ternal

foldsof

thevu

lvain

wom

enus

ingpa

dsforleak

agean

d/or

disc

harge.

Vag

inaldilators

may

beof

bene

fitintheman

agem

ento

fvaginism

usan

d/or

vagina

lsteno

sisan

dca

nbe

offered

toan

yone

having

pain

with

exam

inations

and/or

sexu

alac

tivity

.Thisis

particularly

impo

rtan

tfor

wom

entrea

tedwith

pelvic

(orva

gina

l)radiation

therap

y.Idea

lly,b

enefitisgrea

test

whe

nstartedea

rlyan

dsh

ould

notbe

reco

mmen

dedba

sedon

sexu

alac

tivity

orse

xual

orientationbu

t,rather,toallw

omen

atris

kforva

gina

lcha

nges

tobe

proa

ctivein

their

sexu

alan

dvu

lvov

aginal

health.

Cog

nitiv

ebe

havioral

therap

yan

dpe

lvic

floor

(Keg

el)

exercise

smay

beus

eful

tode

crea

sean

xietyan

ddisc

omfort

andca

nlower

urinarytrac

tsy

mptom

s.Th

eExp

ertPan

elbe

lieve

sthat

pelvic

floo

rph

ysiotherap

ymay

bebe

nefic

ialfor

patie

nts

expe

rienc

ingsy

mptom

sof

apo

tentialp

elvicflo

ordy

sfun

ction,

includ

ingpe

rsistent

pain

andurinary

and/or

feca

llea

kage

.Clin

icians

may

referpa

tientsto

aurolog

istor

urog

ynec

olog

istforfurthe

rev

alua

tion

andtrea

tmen

tof

urinaryinco

ntinen

ceor

toaco

lorectal

surgeo

nforfeca

linc

ontin

ence

.

ASCO

Qua

lifying

Statemen

t.The

reis

limite

dsu

pportiv

eda

taon

theus

eof

vagina

lde

hydroe

pian

dosteron

ein

wom

enwith

ahistory

ofca

ncer

oron

endo

crinetherap

y,so

theris

k/be

nefit

forthis

popu

latio

nis

notfully

know

n.Osp

emife

neha

sno

tbe

enev

alua

tedin

wom

enwith

ahistoryof

canc

eror

onen

docrinetherap

y,an

dtherefore,

theris

k/be

nefit

isno

tkn

ownfor

this

popu

latio

n.A

thorou

ghdisc

ussion

outlining

theun

certaintysh

ould

beha

dwith

thepa

tient.

(con

tinue

don

followingpa

ge)


Carter et al


Table1.

Orig

inal

CCO

andASCO

Ada

pted

Rec

ommen

datio

nsan

dQua

lifying

Statemen

ts(con

tinue

d)

CCO

Rec

ommen

datio

nCCO

Qua

lifying

Statemen

tASCO

Ada

pted

Rec

ommen

datio

nASCO

Qua

lifying

Statemen

t

Formen

with

canc

er:

Sex

ualres

pons

eRec

ommen

datio

n1.

Itis

reco

mmen

dedthat

PDE5i

med

ications

beus

edto

help

men

with

erec

tiledy

sfun

ction.

Men

who

dono

tresp

ondto

PDE5i

med

ications

shou

ldco

nsider

alternate

interven

tions

,su

chas

aVED,med

icated

urethral

system

forerec

tion,

orintracaverno

salinjec

tion.

Theremay

beso

mebe

nefitto

initiatingthe

useof

anyof

theab

oveinterven

tions

earlier

aftercanc

ertrea

tmen

trather

than

later.

TheExp

ertPan

elbe

lieve

sthat

men

arebe

stse

rved

bybe

ingofferedaco

mbina

tionof

psycho

social

coun

selingwith

theaim

ofgrea

ter

adap

tatio

ntowardlong

-term

usean

dPDE5i

med

icationad

herenc

etoge

ther

with

PDE5i

trea

tmen

t.Fo

rmen

who

arepa

rtne

red,

psycho

social

coun

selingsh

ould

bedirected

atthe

coup

le.

Men

shou

ldbe

awarethat

itmight

take

along

time

formed

ications

towork.

Itistheop

inionof

theExp

ertP

anel

that

anykind

ofregu

larstim

ulation(in

clud

ingmasturbation)

wou

ldlikelybe

ofbe

nefitforim

prov

ingse

xual

resp

onse

,rega

rdless

ofthestim

ulationus

ed.

Con

traind

ications

includ

etheus

eof

nitrates

inan

yform

.Com

mon

acutead

verseeffectsof

PDE5i

med

ications

includ

ehe

adac

hes,

flus

hing

,dizzines

s,up

setstom

ach,

nasalc

onge

stion,

and

dysp

epsia.

Rec

ommen

datio

n1.

Itis

reco

mmen

dedthat

PDE5i

med

ications

beus

edto

help

men

with

erec

tile

dysfun

ction.

Men

who

dono

tres

pond

toPDE5i

med

ications

shou

ldco

nsider

alternateinterven

tions

,su

chas

aVED,

med

icated

urethral

system

forerec

tion,

orintracaverno

salinjec

tion.

Theremay

beso

mebe

nefitto

initiatingtheus

eof

any

oftheab

oveinterven

tions

earlier

afterc

ance

rtreatmen

trather

than

later.Introd

uctio

npriorto

trea

tmen

tinitiationmay

beof

bene

fitto

somemen

.Surgica

linterve

ntions

,includ

ingpe

nile

pros

thes

isim

plan

tatio

nforerec

tiledy

sfun

ction,

canbe

offered

topa

tientswho

areno

tresp

onding

toco

nven

tiona

lmed

ical

therap

yor

repo

rtingad

verseeffectswith

such

therap

y.Clin

icians

may

referpa

tientsto

aurolog

istfor

evalua

tionan

dtrea

tmen

tof

stress

urinary

inco

ntinen

ce.

ASCO

Qua

lifying

Statemen

t.Th

eExp

ertPan

elbe

lieve

sthat

men

arebe

stse

rved

bybe

ingoffered

aco

mbina

tionof

psyc

hoso

cialco

unse

lingwith

the

aim

ofgrea

tera

daptationtowardlong

-term

usean

dPDE5i

med

icationad

herenc

etoge

ther

with

PDE5i

trea

tmen

t.Fo

rmen

who

arepa

rtne

red,

psyc

hoso

cial

coun

selingsh

ould

bedirected

atthe

coup

le.

Men

shou

ldbe

awarethat

itmight

take

along

time

formed

ications

toworkan

dthat

PDE5

imed

ications

might

notworkforallm

en,

espe

cially

inthos

ewith

pree

xisting

comorbiditie

s.Clin

icians

shou

lddisc

usswith

patie

ntstheap

prop

riate

duratio

nof

usean

dalternativeop

tions

(eg,

surgery)

ifthe

med

ications

failto

worksa

tisfactorily

.Itistheop

inionof

theExp

ertP

anel

that

anykind

ofregu

larstim

ulation(in

clud

ingmasturbation)

wou

ldlikelybe

ofbe

nefitforim

prov

ingse

xual

resp

onse

,rega

rdless

ofthestim

ulationus

ed.

Con

traind

ications

includ

etheus

eof

nitrates

inan

yform

.Com

mon

acutead

verseeffectsof

PDE5i

med

ications

includ

ehe

adac

hes,

flus

hing

,dizzines

s,up

setstom

ach,

nasalc

onge

stion,

and

dysp

epsia.

Gen

italc

hang

esRec

ommen

datio

n2.

Itis

reco

mmen

dedthat

aVED

beus

edda

ilyto

prev

entpe

nisleng

thloss

.Th

eremay

beso

mebe

nefitto

initiating

theus

eof

VEDsea

rlier

afterc

ance

rtreatmen

trather

than

later.Early

trea

tmen

twith

PDE5i

med

ications

may

also

bebe

neficial

forthis

outcom

e.

Non

eRec

ommen

datio

n2.

Itisreco

mmen

dedthat

aVED

beus

edda

ilyto

prev

entpe

nisleng

thloss

.The

remay

beso

mebe

nefitto

initiatingtheus

eof

VEDsea

rlier

after

canc

ertrea

tmen

trathe

rtha

nlater.Earlytrea

tmen

twith

PDE5i

med

ications

may

also

bebe

neficial

forthis

outcom

e.

Non

e

Intim

acy/relatio

nships

Rec

ommen

datio

n3.

TheExp

ertPan

elbe

lieve

sthat

individu

alor

coup

lesco

unse

ling

shou

ldbe

offeredforthos

ewishing

toim

prov

erelatio

nshipor

intim

acyissu

es.

Current

eviden

cedo

esno

tsup

portapa

rticular

interven

tionto

improv

eintim

acyor

relatio

nships

.

Non

eRec

ommen

datio

n3:

TheExp

ertPan

elbe

lieve

sthat

individu

alor

coup

lesco

unse

lingsh

ould

beofferedfor

thos

ewishing

toim

prov

erelatio

nshipor

intim

acy

issu

es.C

urrent

eviden

cedo

esno

tsu

pportapa

rticular

interven

tionto

improv

eintim

acyor

relatio

nships

.

ASCO

Qua

lifying

Statemen

t.The

oppo

rtun

ityfor

partne

rsto

beinvo

lved

shou

ldbe

offeredrather

than

view

edas

ane

cessaryco

ndition

.

(con

tinue

don

followingpa

ge)




http://jco.org

Table1.

Orig

inal

CCO

andASCO

Ada

pted

Rec

ommen

datio

nsan

dQua

lifying

Statemen

ts(con

tinue

d)

CCO

Rec

ommen

datio

nCCO

Qua

lifying

Statemen

tASCO

Ada

pted

Rec

ommen

datio

nASCO

Qua

lifying

Statemen

t

Ove

rallse

xual

func

tioning

andsatis

faction

Rec

ommen

datio

n4.

Itis

reco

mmen

dedthat

psyc

hoso

cial

coun

selingbe

offeredto

men

with

canc

er(and

partne

rs)to

potentially

improv

ese

xualfunc

tioning

andsatis

faction.

Itis

also

reco

mmen

dedthat

theus

eof

pro-

erec

tileag

ents

andde

vice

sbe

cons

idered

,reco

gnizingthat

mos

tof

thebe

nefitis

spec

ifically

forerec

tiledy

sfun

ction.

Psy

chos

ocialc

ouns

elingco

uldbe

used

tohe

lpco

uplesintegrateinterven

tions

into

theirus

ual

sexu

alactiv

ities

.

Rec

ommen

datio

n4.

Itis

reco

mmen

dedthat

psycho

socialco

unse

lingbe

offeredto

men

with

canc

er(and

partne

rs)topo

tentially

improv

ese

xualfunc

tioning

andsatis

faction.

Itisalso

reco

mmen

dedthat

theus

eof

pro-erec

tileag

ents

andde

vice

sbe

cons

idered

,reco

gnizingthat

mos

tof

thebe

nefitis

spec

ifically

for

erec

tiledy

sfun

ction.

With

men

who

have

sexwith

men

,add

ition

aled

ucationmay

need

tobe

prov

ided

onthech

ange

sin

erec

tionan

dalternativeway

sto

maintainse

xual

intim

acy.

Bod

yim

age,

includ

ingsu

chissu

esas

weigh

tcha

nges

,disfigurem

ent,

scarrin

g,an

dha

irloss,sh

ould

bedisc

usse

dan

dno

rmalized

inmen

.Clin

icians

shou

ldch

ecktestos

terone

leve

ls,ev

enif

thepa

tient

hasaca

ncer

that

isno

ttypica

llyas

sociated

with

horm

onech

ange

s.Options

shou

ldbe

disc

usse

dwhe

ntestos

terone

leve

lsarewith

inno

rmal

rang

ebu

tthepa

tient

orclinicianfeels

supp

lemen

tatio

nca

nha

veaclinical

bene

fitan

disno

tco

ntraindica

ted.

Psy

chos

ocialc

ouns

elingco

uldbe

used

tohe

lpco

uplesintegrateinterven

tions

into

theirus

ual

sexu

alactiv

ities

.

Vas

omotor

symptom

sRec

ommen

datio

n5.

Men

with

vaso

motor

symptom

ssh

ould

beofferedmed

icationfor

symptom

atic

improv

emen

ts.Options

wou

ldinclud

eve

nlafax

ine,

med

roxy

prog

esterone

acetate,

cyproteron

eac

etate,

andga

bape

ntin.

Acu

punc

ture

may

beasu

itablealternative.

Non

eRec

ommen

datio

n5.

Men

with

vaso

motor

symptom

ssh

ould

beofferedmed

icationforsy

mptom

atic

improv

emen

ts.Options

wou

ldinclud

eve

nlafaxine,

med

roxy

prog

esterone

acetate,

cyproteron

eac

etate,

andga

bape

ntin.Acu

punc

ture

may

beasu

itable

alternative,

asmay

beothe

rintegrativemed

icine

optio

ns,su

chas

slow

-breathing

tech

niqu

esan

dhy

pnos

is,a

sev

iden

cede

mon

stratesclinicalbe

nefit

inwom

en.

Psyc

hoso

cial

coun

selin

g(cog

nitiv

ebe

havioral

therap

y)may

prov

ideabe

nefit

andredu

ceva

somotor

symptom

san

dsh

ould

beoffered.

ASCO

Qua

lifying

Statemen

t.Ev

iden

cesu

pportin

gtheclinical

effectiven

essof

vario

usintegrativemed

icinetech

niqu

esex

ists

for

wom

enex

perie

ncingva

somotor

symptom

s.16-19

The

ASCO

Expe

rtPa

nelfee

lsex

trap

olationto

malepa

tientsisreas

onab

lean

dan

optio

nform

ensu

fferingfrom

vaso

motor

symptom

s.

NOTE

.Add

ition

alASCOExp

ertP

anelstatem

ents

anded

itsto

originalCCOstatem

ents

appe

arinbo

ldita

lics.Abb

reviations

:CCO,C

ance

rCareOntario;P

DE5i,p

hosp

hodies

terase

type

5inhibitor;VED,vac

uum

erec

tile

device

.


Carter et al


evidence may emerge between the time information is developedand when it is published or read. The information is not con-tinually updated and may not reflect the most recent evidence. Theinformation addresses only the topics specifically identified thereinand is not applicable to other interventions, diseases, or stages ofdiseases. This information does not mandate any particular courseof medical care. Further, the information is not intended to sub-stitute for the independent professional judgment of the treatingprovider, as the information does not account for individual vari-ation among patients. Recommendations reflect high, moderate, orlow confidence that the recommendation reflects the net effect ofa given course of action. The use of words like “must,” “must not,”“should,” and “should not” indicate that a course of action is rec-ommended or not recommended for either most or many patients,but there is latitude for the treating physician to select other coursesof action in individual cases. In all cases, the selected course of actionshould be considered by the treating provider in the context oftreating the individual patient. Use of the information is voluntary.ASCO provides this information on an “as is” basis, and makes nowarranty, express or implied, regarding the information. ASCOspecifically disclaims any warranties of merchantability or fitness fora particular use or purpose. ASCO assumes no responsibility for anyinjury or damage to persons or property arising out of or related toany use of this information or for any errors or omissions.

Guideline and Conflicts of InterestThe Expert Panel was assembled in accordance with ASCO’s

Conflict of Interest Policy Implementation for Clinical PracticeGuidelines (“Policy,” found at http://www.asco.org/rwc). Allmembers of the Expert Panel completed ASCO’s disclosure form,which requires disclosure of financial and other interests, includingrelationships with commercial entities that are reasonably likely toexperience direct regulatory or commercial impact as a result ofpromulgation of the guideline. Categories for disclosure includeemployment; leadership; stock or other ownership; honoraria,consulting or advisory role; speaker’s bureau; research funding;patents, royalties, other intellectual property; expert testimony; travel,accommodations, expenses; and other relationships. In accordancewith the Policy, the majority of the members of the Expert Panel didnot disclose any relationships constituting a conflict under the Policy.

CLINICAL QUESTION AND TARGET POPULATION

The guideline, Interventions to Address Sexual Problems in PeopleWith Cancer, addressed the effectiveness of pharmacological in-terventions, psychosocial counseling, or devices to manage sexualproblems after cancer treatment in both men and women. Thecomplete set of recommendations are provided in Table 1.

The target population for the guideline, Interventions toAddress Sexual Problems in People With Cancer, is adult ($ 18years) men and women (and their partners) of all sexual orien-tations living with or surviving from cancer of any type. For thepurposes of this guideline, men and women who were previouslytreated for a childhood cancer were not included. Although out ofthe scope of this guideline, the Expert Panel believes that adolescents(younger than 18) with cancer also require a tailored discussion

regarding sexual health and fertility, even if they are not yet sexuallyactive. Further discussion of special issues affecting the adolescentand young adult population with cancer are found elsewhere.27,28

SUMMARY OF THE CCO GUIDELINEDEVELOPMENT METHODOLOGY

The CCO guideline was developed by an author Expert Panel anda Scientific Advisory Panel that included experts in gynecology,urology, medical oncology, radiation oncology, psychology, psy-chiatry, behavioral sciences, supportive care, and sexual health. Theliterature search of OvidMEDLINE, EMBASE, CINAHL, PsycINFO,and Cochrane Database was conducted on March 6, 2013. Owing tothe lack of intervention studies identified, including patients withhematologic cancer, separate searches were also run onMay 1, 2014,in the same databases. Details of the search strategies and the studyinclusion criteria and outcomes of interest are available at https://www.cancercareontario.ca/en/content/interventions-address-sexual-problems-people-cancer.

The searches identified 103 studies for inclusion in the guideline’squalitative synthesis of the literature. The CCO panel reviewed datafrom systematic reviews and primary studies covering sexual response,body image, intimacy and relationships, vasomotor symptoms, genitalsymptoms, and overall sexual function and satisfaction.

RESULTS OF THE ASCO METHODOLOGY REVIEW

The methodology review of the guideline, Interventions to AddressSexual Problems in People With Cancer, was completed in-dependently by two ASCO guideline staff members using the Rigorof Development subscale from the AGREE II instrument. TheRigor subscale consists of seven items that assess the quality of theprocesses used to gather and synthesize the relevant data and themethods used to formulate the guideline recommendations. Itemssuch as the use of systematic methods in the search of the evidence,explicit links between the recommendations and the evidence, andconsideration of benefits and risks were assessed. Each subscale itemis rated on a seven-point scale from 1 (strongly disagree) to 7(strongly agree). Detailed results of the scoring for this guideline areavailable upon request to [email protected]. Overall, the guideline,Interventions to Address Sexual Problems in People With Cancer,itself scored 80%. There were someminor deficiencies with reportingon the methods for formulating the recommendations and on thestrengths and limitations of the evidence considered (see Method-ology Supplement at www.asco.org/survivorship-guidelines).

The preliminary ASCO content reviewers of the Interventionsto Address Sexual Problems in People With Cancer as well as theASCO Expert Panel found the recommendations to be clear andthorough in the original guideline. Each section, including theguideline recommendations, the evidentiary base, and the devel-opment methods and external review process, was clear and wellreferenced from the systematic review.

This is the most recent information as of the publication date.For updates, the most recent information, and to submit newevidence, please visit www.asco.org/survivorship-guidelines andthe ASCO Guidelines Wiki (www.asco.org/guidelineswiki).




http://www.asco.org/rwc







http://jco.org

RESULTS OF THE ASCO CONTENT REVIEW

The ASCO Expert Panel reviewed the guideline, Interventions toAddress Sexual Problems in People With Cancer, and concurs thatthe recommendations are clear, thorough, and based on the mostrelevant scientific evidence in this content area and present optionsthat will be acceptable to patients. For the most part, the ASCOExpert Panel agrees with the recommendations as stated in theguideline, but modifications and further qualifications are made.

METHODS AND RESULTS OF THE ASCO UPDATEDLITERATURE REVIEW

This systematic review-based guideline product was developed byan Expert Panel with multidisciplinary, including patient, repre-sentation and by ASCO guidelines staff with health research

methodology experience. ASCO guidelines staff updated the In-terventions to Address Sexual Problems in People With Cancerliterature search. PubMed was searched up to April 3, 2017. Thesearch was restricted to articles published in English. The updatedsearch was guided by the “signals”29 approach that is designed toidentify only new, potentially practice-changing data—signals—thatmight translate into revised practice recommendations. The approachrelies on targeted routine literature searching and the expertise ofASCO Expert Panel members to help identify potential signals. TheMethodology Supplement (available at www.asco.org/survivorship-guidelines) provides additional information about the signalsapproach.

The updated search yielded 159 records. A review of theseresults plus studies identified by searching reference lists andknown seminal papers resulted in 19 new, recommendation-changing studies being included.14-18,20,22-26,30-36,152 Table 2summarizes the number and types of studies included per sex-ual dysfunction condition.

Table 2. Symptoms and Interventions for Sexual Dysfunction (adapted from CCO guideline)

Symptom Possible Intervention Evidence

For women with cancerDifficulty with sexual response,such as desire, arousal, ororgasm

Psychosocial counseling, psychosexual counselingRegular stimulation (including masturbation)Flibanerin for premenopausal women

Two systematic reviews14,15

Two RCTs56,57

Three other58-60

Body image Psychosocial counseling, couples-based interventions Two systematic reviews61,62

Six RCTs56,57,63-66

One other67

Intimacy/relationships Psychosocial counseling, couples-based interventions Zero systematic reviewsFive RCTs56,57,63,64,68

Three other59,60,67

Overall sexual functioning andsatisfaction

Psychosocial counseling, education and symptommanagement, mental healthcounselingPhysical exercise or pelvic floor physiotherapy

Four systematic reviews61,69-71

Eleven RCTs57,63-66,68,72-76

Five other59,60,67,77,78

Vasomotor symptoms Psychosocial counseling (cognitive behavioral therapy)Paroxetine, fluoxetine (should not be offered to women with breast cancertaking tamoxifen), venlafaxine, gabapentin, or clonidineIntegrative approaches, such as clinical hypnosisEstrogen therapy alone (oral, transdermal, or vaginal) when not contraindicated;hormone therapy (for women with non–hormone-sensitive cancers)

Three guidelines19,79,80

One position statement19

Zero systematic reviewsSeven RCTs16-18,65,66,75,76

Genital symptoms, includingdyspareunia, vaginal atrophy,or other vaginal pain

Cognitive behavioral therapyExercise, pelvic floor physiotherapyVaginal moisturizers, lubricants, vaginal estrogen, liquid sealants, vaginaldilatorsSelective estrogen receptor modulator ospemifene (for postmenopausalwomen without a current or history of breast cancer)Lidocaine dehydroepiandosteronePain relievers (for women on aromatase inhibitors)

Two guidelines79,81

Three systematic reviews26,70,71

Eleven RCTs20,22-25,65,66,72,75,82,152

Four other78,83,84,151

For men with cancerSexual response, includingerectile dysfunction

PDE5i medications, VED, medicated urethral system, intracavernosal injectionSurgical intervention, including penile and testicular prosthesesPsychosocial counselingRegular stimulation (including masturbation)


Twenty RCTs87-116

Twenty-sixother30-36,77,111-113,117-131

Genital changes, body image VEDPDE5i medications

Zero systematic reviewsTwo RCTs98,104

One other114

Intimacy/relationships Individual or couples counseling One systematic review102,132

Five RCTs102,103,110,133,134

Three other116,135,136

Overall sexual functioning andsatisfaction

Psychosocial counselingPro-erectile agents and devices


Six RCTs89,98,105,110,138,139

Three other77,116,140

Vasomotor symptoms Venlafaxine, medroxyprogesterone acetate, cyproterone acetate, andgabapentinAcupuncture, hypnosisPsychosocial counseling (cognitive behavioral therapy)

Seven RCTs16-18,115,141-143

Seven other144-150

Abbreviations: CCO, Cancer Care Ontario; PDE5i, phosphodiesterase type 5 inhibitor; RCT, randomized controlled trial; VED, vacuum erectile device.


Carter et al




Characteristics and Quality Assessment of IncludedStudies

Three systematic reviews,14,15,26 nine randomized controlledtrials (RCTs),16-18,20,22-25,152 and seven observational studies30-36

were identified and met the inclusion criteria for the updatedliterature review.

Two systematic reviews14,15 collected RCT evidence andconducted meta-analyses to assess the efficacy and safety of fli-banserin in the treatment of hypoactive sexual desire disorder inwomen. Three RCTs16-18 investigated clinical hypnosis as a non-hormonal treatment of hot flashes in women. One systematicreview with meta-analysis26 and two RCTs24,25 assessed the efficacyand safety of ospemifene in treating dyspareunia associated withpostmenopausal vulvar and vaginal atrophy. Three RCTs in-vestigated intravaginal dehydroepiandrosterone on moderate tosevere dyspareunia and vaginal dryness, symptoms of vulvovaginalatrophy, and the genitourinary syndrome of menopause,20-22 andone RCT considered lidocaine in breast cancer survivors withsevere penetrative dyspareunia.152 Finally, seven observationalsurgical studies investigated penile prosthesis for erectile dys-function and testicular prosthesis for patients who have undergoneorchiectomy for cancer of the testis.30-36 While none of the studieswere found to have serious methodological flaws that would raiseconcerns about the findings, the inherent limitations of surgicalobservational studies should be taken into consideration. Surgicalstudies tended to include a relatively small number of patients, andsome studies only reported short follow-up times.30,31,33,36

Outcomes of Included StudiesIn 2015, the US Food and Drug Administration approved

flibanerin as a treatment of hypoactive sexual desire disorder inpremenopausal women.14 Two systematic reviews with meta-analyses examined the effectiveness of flibanserin on primaryoutcomes, such as satisfying sexual events, sexual desire score, andfemale sexual function index.14,15 Both found statistically signif-icant effects in women randomized to flibanserin compared withthose randomized to placebo. However, there also appeared to bea statistically significant increase in the risk of adverse effects suchas dizziness, somnolence, nausea, and fatigue.

Three RCTs examined the effect of hypnosis16-18 on reductionof vasomotor symptoms in postmenopausal women with orwithout a history of breast cancer. Each study found that hypnosisresulted in significant reductions in self-reported and physiolog-ically measured hot flashes and hot flash scores in women. Ad-ditional benefits such as reduced anxiety and depression andimproved sleep were also observed.17

One systematic review,26 one pooled analysis of two RCTs,24 andone additional RCT25 investigated ospemifene, a selective estrogenreceptor modulator, for the treatment of vulvovaginal atrophy anddyspareunia in postmenopausal women. All studies found a statisti-cally significant improvement in primary outcomes that includedfemale sexual dysfunction, vaginal dryness, dyspareunia, and vaginaland/or vulvar irritation/itching compared with placebo.

Three RCTs investigating intravaginal dehydroepiandrosterone(prasterone) in postmenopausal women all showed improvements inthe signs and symptoms of vaginal atrophy, including pain at sexualactivity, vaginal dryness, vaginal pH, and arousal/sensation.20-23

Serum steroid levels appear to remain within normal post-menopausal values.20-23

In another RCT of 46 estrogen-deficient breast cancer sur-vivors with severe penetrative dyspareunia, less pain during in-tercourse was reported with 4% aqueous lidocaine use comparedwith saline.152 There was a statistically significant decrease in sexualdistress (median score, 14; interquartile range, 3 to 20; P , .001),and sexual function improved in all but one domain with lidocaineuse. Of prior abstainers from intercourse who completed the study,85% had resumed comfortable penetrative intimacy.152

Seven observational studies investigated penile prosthesis forerectile dysfunction and testicular prosthesis for patients who haveundergone orchiectomy for cancer of the testis. Studies evaluatingthe efficacy, safety, and satisfaction with penile prosthesis im-plantation in men with various etiologies of erectile dysfunction,including consequence of radical prostatectomy and other pelvicsurgery, vascular and metabolic syndrome, and spinal trauma,found the implants to be safe and efficacious with high patient andpartner satisfaction.30-34 While the surgical techniques and types ofimplants used differed in these studies, overall results appear to beconsistent. Statistically and/or clinically significant improvementswere found in the mean International Index of Erectile Function-5(IIEF-5) scores,30,32,33 Erectile Dysfunction Inventory of TreatmentSatisfaction (EDITS) scores,30,31 Erection Harness Score,34 andGlobal Assessment Questionnaire (GAQ) scores.34

High overall satisfaction with testicular implants is reportedand ranges from 73% to 97%.35 However, dissatisfaction withseveral particular attributes of the implants have been reported,namely the shape, consistency, size, and high intrascrotal posi-tion.35 Acceptance rate appears to vary with age, such that thelikelihood of accepting a prosthesis decreases with increasing age.35

Psychological assessments measuring anxiety during sexual activityand desires and attempts to selectively avoid exposing one’s body(or parts of one’s body) to sexual partners (Body Exposure duringSexual Activities Questionnaire) showed statistically significantimprovements with testicular implants (P, .001).36 Similarly, theBody-Esteem Scale, whichmeasures self-confidence of each patienttoward sexuality, also showed statistically significant improvementswith the implants (P , .001).36 Interference with sexual activity,erectile functioning, or ejaculation was not observed.36

DISCUSSION

The CCO recommendations were adapted by a multidisciplinarygroup of experts using evidence from the supplementary literaturesearch and clinical experience as a guide. The majority of therecommendation text is listed verbatim from the guideline;however, there are some instances where the ASCO Expert Panelmade modifications or additions to the recommendations for thebroader ASCO audience and to reflect local context and updatedempirical evidence. These changes are identified by bold italics inthe Bottom Line Box and Table 1 and discussed further below.

Initiate at Each VisitThe Expert Panel strongly recommends designation of

a specific treatment team member to query and discuss with each




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patient any impact of cancer or cancer treatment on his/hersexuality. All patients should be provided with disease- andtreatment-specific education and symptom management. Clini-cians should initiate a discussion with the patient at the time ofdiagnosis and inquire about function periodically across treatmentand into follow-up. For patients reporting problems in function,a diagnosis should be established when there are physical issuesplaying a contributing role. For women having persistent physicalconcerns, a gynecologic exam would be important. For women ormen who disclose relationship difficulties and/or distress, referralfor marital therapy should be available.

This guideline and its recommendations are patient focused,and inclusion of others, such as a partner, is the prerogative of thepatient. It was acknowledged that psychosexual education is dif-ferent from psychosocial education as sexual health and intimacy isoften omitted in the latter conversations. Furthermore, clarifica-tion should be made about the difference between sex counselingand sex therapy. However, absence of a specialized sex therapistshould not be a reason for lack of discussion. Patients can stillbenefit by counseling provided by available generic counselors whocan help normalize the experience and increase support andguidance when a specialized sex therapist is not available. Ideally,education about the potential effect of cancer treatments on sexualfunction should be part of the informed consent process as well asany dialogue around plans for symptom management wheretherapies used themselves may affect sexual function (eg, painmedications, steroid use, antidepressants, etc). Discussions shouldbe congruent with the patient’s literacy level, cultural/religiousbeliefs, and sexual orientation.

ResourcesA key barrier to the delivery of optimal sexual care of patients

with cancer and survivors is lack of awareness of whom or whatmay be available to address sexual problems or concerns whenraised. Clinicians are encouraged to conduct a landscape review ofkey personnel and local resources to address sexual health withinand proximate to their practice as a first step. Because these maychange over time, an annual update of this list may be needed. TheExpert Panel felt it equally important for clinicians to be madeaware of high-quality national resources available for both patients(and their partners) and clinicians to help with education, as-sessment, andmanagement of this distinct problem. The AmericanCancer Society (www.cancer.org) and the National Cancer In-stitute (www.cancer.gov) both have comprehensive patient in-formational booklets about sex after cancer. Internationalresources are also available and include the MacMillan CancerSupport Community in the United Kingdom (www.macmillan.org.uk), the Cancer Council of Australia (www.cancercouncil.com.au), and the Scientific Network on Female Sexual Health andCancer (www.cancersexnetwork.org).9

Finding ways to ask about and assess sexual function is im-portant. General screening tools include those from the NationalComprehensive Cancer Network9 and Patient-Reported OutcomesMeasurement Information System (PROMIS-1) item screener.37

Gender-specific tools include the Brief Sexual Symptom Check-list38 (note: this scale has been adapted for use specifically in femalepatients with cancer9), Arizona Sexual Experience Scale (ASEX),39

and Female Sexual Function Index (FSFI) for women.40 For men,the Sexual Health Inventory for Men (SHIM),41 Sexual Quality ofLife Male (SQoL-M),42 and PROMIS are options. (Of note, FSFIand ASEX have been validated/used in cancer survivors; othershave not.) Use of standardized, validated measures are recom-mended for screening and assessment. Consideration should begiven to routine use of a simple screening measure in the clinicalsetting. This may help ensure that issues related to sexual health areidentified and addressed; it can also help send a message to patientsthat addressing sexual problems is an important part of theircancer care.

Professional organizations also exist to help clinicians identifyand facilitate connections with specialists in various areas of ex-pertise. Sexual health counselors and therapists with expertise intreating cancer survivors can be located through the AmericanAssociation of Sexuality Educators, Counselors, and Therapists orthe Society for Sex Therapy and Research. Additional resources formen can be found at Sexual Medicine Society of North America(www.sexhealthmatters.org). Resources specific for women in-clude the International Society for the Study of Women’s SexualHealth (www.isswsh.org); The North American Menopause So-ciety (www.menopause.org); the American Association of Sexu-ality Educators, Counselors and Therapists (www.aasect.org); andthe Society for Sex Therapy and Research (www.starnet.org).

Different Diagnoses Need Different ManagementThe ASCO Expert Panel noted the importance of broadly

recognizing that different sexual problems will have differentmanagement strategies. It is important to consider both thephysical as well as the psychosocial care appropriate for each ofthese. Furthermore, attention needs to be given to the fact thatsexual satisfaction is not dependent on (and should not be nar-rowly defined as) the ability to engage in intercourse. Consider-ation should be given to the multiple ways of achieving sexualsatisfaction for oneself, with or without a partner.

Across care, it is important to recognize that when adverseeffects of treatment contribute to sexual dysfunction (eg, painsyndromes secondary to use of an aromatase inhibitor for womenor erectile dysfunction secondary to hormonal therapy amongmen), this can lead to nonadherence or even discontinuation ofcancer therapy. Providing information about and, as needed, relieffrom these (eg, pain medication for use with aromatase inhibitors)can improve sexual function. In general, improved symptommanagement leads to improved sexual response.43

Patients at high risk of cancer who choose to undergo cancerrisk–reducing surgeries, such as bilateral mastectomy and/or oo-phorectomy, may also experience an effect on sexual functioning.Clinicians should be aware that while the target population of thisguideline is people with cancer, the management strategies andsupport for patients undergoing prophylactic surgery should re-main the same as outlined in this guideline.

Overall Sexual Functioning and Satisfaction for WomenRecommendation

The Expert Panel noted that current recommendations didnot address the important role of symptom management and itseffect on the sexual response. Improved symptom management


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can be associated with improvement in the domains of the sexualresponse.44 To this end, any underlying physical issue contributingto sexual dysfunction should be identified and managed.

Sexual Response for Men RecommendationsBody image is important to men’s sexual health. Issues such as

weight change, increase in breast size, disfigurement, scarring, andhair loss should also be discussed and normalized in men. Nor-malizing these issues may help men reach a new comfort level withbody image and functioning following their cancer.

In considering potential physical contributions to men’ssexual function, clinicians should check testosterone levels, even ifthe patient has a cancer that is not typically associated withhormone changes. Options for potential supplementation shouldbe discussed as indicated, including when testosterone levels arewithin normal range but the patient or clinician feels supple-mentation could have a clinical benefit and is not contraindicated.

Additional management options not covered in the CCOguideline warrant further discussion, including surgical inter-ventions for erectile dysfunction. For patients refractory to medicaltherapy with oral phosphodiesterase type 5 inhibitors and intra-cavernosal vasoactive agents, penile prosthesis implant remainsa relevant and desired option.45 Indeed, penile implants haveprovided a predictable and reliable way for restoring erections inthose patients for whommore-conservativemeasures have failed.46

Available modern models have improved durability and operabilityand are less prone to wear.46 As such, any patient with cancer inwhom more conservative measures for erectile dysfunction havefailed should be offered a discussion of the risks and benefits ofprosthesis implantation surgery. Guidelines from the AmericanUrological Association recommend that any patient consideringprosthesis implantation should be informed of the types ofprostheses available and made aware of possible adverse events,including infection, erosion, mechanical failure, and penileshortening.47 Referral to urology is appropriate for these patients.

HEALTH DISPARITIES

ASCO clinical practice guidelines represent expert recommenda-tions on the best practices in disease management to provide thehighest level of cancer care. However, many have limited access tohealth care. Racial and ethnic disparities in health care contributesignificantly to this problem in the United States. Racial/ethnicminorities suffer disproportionately from comorbidities, experi-ence more substantial obstacles to receiving care, are more likely tobe uninsured, and are at greater risk of receiving care of poorquality than other Americans.48-51 Many other patients lack accessto care because of their geographic location and distance fromappropriate treatment facilities. Awareness of these disparities inaccess to care should be considered in the context of this clini-cal practice guideline, and health care providers should strive todeliver the highest level of cancer care to these vulnerablepopulations.

Medically underserved populations may also suffer from lowgeneral literacy, low health literacy, and language and cultural

differences that can make assessment of sexual health a challenge.52

In the general population, low socioeconomic status is associatedwith a higher prevalence of sexual problems, and evidence suggeststhat cancer survivors in medically underserved populations havehigh rates of sexual inactivity and sexual dysfunction.52

Sexual and gender minority populations are another diversegroup at risk for receiving disparate care and suboptimal expe-riences with their health care journey.53 While not well studied,some evidence suggests that predictors of sexual function aftercancer do not differ by sexual orientation.10 Regardless, sexual andgender minorities should have access to culturally sensitive andcompetent support services (www.lgbtcancer.org).

Ultimately, health care providers should strive to offer dis-cussions and materials congruent with the survivor’s literacy level,cultural or religious beliefs, and sexual orientation. It is paramountfor ensuring optimum care for such vulnerable populations.

ADDITIONAL RESOURCES

More information, including a Data Supplement with a reprint ofall Interventions to Address Sexual Problems in People WithCancer guideline recommendations, a Methodology Supplement,slide sets, and clinical tools and resources, is available at www.asco.org/survivorship-guidelines and www.asco.org/guidelineswiki.Patient information is available at www.cancer.net. Visit www.asco.org/guidelineswiki to provide comments on the guideline or tosubmit new evidence.

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTSOF INTEREST

Disclosures provided by the authors are available with this article atjco.org.

AUTHOR CONTRIBUTIONS

Manuscript writing: All authorsFinal approval of manuscript: All authors

Related ASCO Guidelines

• Fertility Guideline54 (http://ascopubs.org/doi/10.1200/jco.2013.49.2678)

• Integration of Palliative Care Into Standard OncologyPractice55 (http://ascopubs.org/doi/10.1200/JCO.2016.70.1474)

• Screening, Assessment, and Care of Anxiety andDepressive Symptoms5 (http://ascopubs.org/doi/10.1200/jco.2013.52.4611)




http://www.lgbtcancer.org







http://jco.org

http://ascopubs.org/doi/10.1200/jco.2013.49.2678


http://ascopubs.org/doi/10.1200/JCO.2016.70.1474

http://ascopubs.org/doi/10.1200/JCO.2016.70.1474



http://jco.org

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AffiliationsJeanne Carter, Katherine DuHamel, and Shari Goldfarb, Memorial Sloan Kettering Cancer Center, New York; Michael A.

Diefenbach, Northwell Health, Manhasset, NY; Christina Lacchetti, American Society of Clinical Oncology, Alexandria; Sage Bolte,Inova, Fairfax, VA; Barbara L. Andersen, Ohio State University, Columbus, OH;Debra L. Barton, University ofMichigan, Ann Arbor, MI;Shari Damast, Yale School of Medicine, New Haven, CT; Judith Florendo, Florendo Physical Therapy, Chicago; Sigrun Hallmeyer,Oncology Specialists SC, Park Ridge, IL; Patricia A. Ganz, University of California, Los Angeles, CA; David M. Kushner, University ofWisconsin, Madison, WI; and Julia H. Rowland, National Cancer Institute, Bethesda, MD.

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AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Interventions to Address Sexual Problems in People With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Adaptation ofCancer Care Ontario Guideline

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships areself-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For moreinformation about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc.

Jeanne CarterNo relationship to disclose

Christina LacchettiNo relationship to disclose

Barbara L. AndersenNo relationship to disclose

Debra L. BartonResearch Funding: Merck Foundation

Sage BolteNo relationship to disclose

Shari DamastNo relationship to disclose

Michael A. DiefenbachNo relationship to disclose

Katherine DuHamelNo relationship to disclose

Judith FlorendoNo relationship to disclose

Patricia A. GanzLeadership: Intrinsic LifeSciences (I)Stock or Other Ownership: Xenon Pharmaceuticals (I), IntrinsicLifeSciences (I), Silarus Therapeutics (I), Merganser Biotech (I), TEVAPharmaceuticals Industries, Novartis, Merck, Johnson & Johnson, Pfizer,GlaxoSmithKline, Abbott LaboratoriesHonoraria: Biogen (I)Consulting or Advisory Role: Keryx Biopharmaceuticals (I), MerganserBiotech (I), Silarus Therapeutics (I), InformedDNA, Vifor Pharma (I), EliLillySpeakers’ Bureau: La Jolla Pharmaceutical Company (I)Research Funding: Keryx Biopharmaceuticals (I)Patents, Royalties, Other Intellectual Property: Related to ironmetabolism and the anemia of chronic disease (I), Up-to-Date royalties forsection editor on survivorshipTravel, Accommodations, Expenses: Intrinsic LifeSciences (I), KeryxBiopharmaceuticals (I)

Shari GoldfarbConsulting or Advisory Role: Sermonix Pharmaceuticals, AMAGPharmaceuticals, Procter & Gamble, Adgero BiopharmaceuticalsResearch Funding: Paxman, Valeant Pharmaceuticals International

Sigrun HallmeyerEmployment: Oncology Specialists SC, Advocate Medical GroupLeadership: Oncology Specialists SC, Advocate Lutheran General HospitalHonoraria: Bristol-Myers Squibb, PfizerConsulting or Advisory Role:Cardinal Health, Bristol-Myers Squibb, KBLBiologicsSpeakers’ Bureau: Bristol-Myers Squibb, PfizerResearch Funding: Russell Research Institute (Inst)Travel, Accommodations, Expenses: Bristol-Myers Squibb, CardinalHealth

David M. KushnerNo relationship to disclose

Julia H. RowlandNo relationship to disclose

© 2017 by American Society of Clinical Oncology JOURNAL OF CLINICAL ONCOLOGY

Carter et al


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Acknowledgment

The Expert Panel thanks Tara Henderson and Eric Singer and the Clinical Practice Guidelines Committee for their thoughtful reviewsand insightful comments on this guideline adaptation.

Appendix

Table A1. Interventions to Address Sexual Problems in PeopleWith Cancer: ASCO Clinical Practice Guideline Adaptation of Cancer Care Ontario Guideline Expert PanelMembership

Name Affiliation

Julia H. Rowland, PhD, co-chair National Cancer InstituteDevelopmental Psychology

Jeanne Carter, PhD, co-chair Memorial Sloan Kettering Cancer CenterClinical Psychology

Barbara L. Andersen, PhD Ohio State UniversityClinical Psychology

Debra L. Barton, PhD University of MichiganNursing

Shari Damast, MD Yale School of MedicineRadiation Oncology

Michael A. Diefenbach, PhD Northwell HealthBehavioral Science

Katherine DuHamel, PhD Memorial Sloan Kettering Cancer CenterClinical Psychology

Judith Florendo, DPT Florendo Physical TherapyPhysical Therapy

Patricia A. Ganz, MD University of CaliforniaBreast Medical Oncology

Shari Goldfarb, MD Memorial Sloan Kettering Cancer CenterBreast Medical Oncology

David M. Kushner, MD University of WisconsinGynecologic Oncology

Sigrun Hallmeyer, MD Oncology Specialists SCMedical Oncology, Practice Guidelines Implementation NetworkRepresentative

Sage Bolte, PhD InovaPatient Representative

Christina Lacchetti American Society of Clinical OncologyStaff/Health Research Methodologist

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